| *First Name: |
|
| *Last Name: |
|
| *Organization: |
|
*Investor Type: |
|
| c/o: |
|
| *Street Address
1: |
|
| Street Address 2: |
|
| *City: |
|
| *State: |
|
| *Zip: |
|
| Country: |
|
| *E-mail: |
|
| *Phone: |
|
| Fax: |
|
| Referred by: |
|
*Comments:
(It is required that you explain the specific reason(s) you seek to register/obtain
non-public information.) |
|
| Accredited Investor Questionnaire |
|
| (At least one selection required) |
|
|
Regulated entity |
|
| I am (i) a U.S. bank or any
banking institution organized under the laws of any state, territory or
the District of Columbia, the business of which is substantially confined
to banking and is supervised by the State or Territorial banking commission
or similar official agency, (ii) a U.S. savings and loan association or
other similar institution, whether acting in its individual or fiduciary
capacity; (iii) a broker or dealer registered pursuant to Section 15 of
the Securities Exchange Act of 1934; (iv) a U.S. insurance company; or
(v) an investment company registered under the Investment Company Act
of 1940. |
| |
|
Business development company
|
|
| I represent a "business
development company"
|
| |
|
Private business development company
|
|
| I am a "private business
development company" as defined in the Investment Advisers Act of
1940. |
| |
|
Small business investment company
|
|
| I am a "small business
investment company" licensed by the U.S. Small Business Administration
under Section 301(c) or 501(c)(3) of the Small Business Investment Act
of 1958. |
| |
|
Entity not formed for the specific purpose
of acquiring the security offered |
| I am an organization described
in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended,
a corporation, a Massachusetts or similar business trust, or partnership,
not formed for the specific purpose of acquiring any specific security,
with total assets in excess of $5,000,000. |
| |
|
Individual (NET WORTH) |
|
| I am a natural person whose
individual liquid net worth, or joint net worth with my spouse, as of
the date hereof exceeds $1,000,000. |
| |
|
Individual (INCOME) |
|
| I am a natural person who
had an individual income in excess of $500,000 in each of the two most
recent years or joint income with my spouse in excess of $500,000 in each
of those years and I have a reasonable expectation of reaching the same
income level in the current year. |
| |
|
State plan |
|
| I am a plan established and
maintained by a State, its political subdivisions, or any agency or instrumentality
of a State or its political subdivisions, for the benefit of its employees,
if such plan has total assets in excess of $20,000,000. |
| |
|
Trust |
|
| I am a trust with total assets
in excess of $5,000,000, not formed for the specific purpose of acquiring
any specific security, whose purchase is directed by a sophisticated person
as described in Regulation D. |
| |
|
Revocable trust |
|
| I am a "revocable trust" that
may be amended or revoked at any time by the grantors thereof, an all
of the grantors are "accredited investors". |
| |
|
Entity
(beneficial owners are accredited investors) |
| I am an entity the beneficial
owners of which are all accredited investors as discussed above. |
| |
|
|